Assessing Indian public health standards for community health centers: A case study with special reference to essential newborn care services

Human resource shortage in India's health sector: a scoping review of the current landscape

BACKGROUND

For healthcare delivery to be optimally effective, health systems must possess adequate levels and we must ensure a fair distribution of human resources aimed at healthcare facilities. We conducted a scoping review to map the current state of human resources for health (HRH) in India and the reasons behind its shortage.

METHODS

A systematic search was conducted in various electronic databases, from the earliest available date till February 2024. We applied a uniform analytical framework to all the primary research reports and adopted the "descriptive-analytical" method from the narrative paradigm. Inductive thematic analysis was conducted to arrange the retrieved data into categories based on related themes after creating a chart of HRH problems.

RESULTS

A total of 9675 articles were retrieved for this review. 88 full texts were included for the final data analysis. The shortage was addressed in 30.6% studies (n = 27) whereas 69.3% of studies (n = 61) addressed reasons for the shortage. The thematic analysis of data regarding reasons for the shortage yielded five kinds of HRH-related problems such as inadequate HRH production, job dissatisfaction, brain drain, regulatory issues, and lack of training, monitoring, and evaluation that were causing a scarcity of HRH in India.

CONCLUSION

There has been a persistent shortage and inequitable distribution of human resources in India with the rural expert cadres experiencing the most severe shortage. The health department needs to establish a productive recruitment system if long-term solutions are to be achieved. It is important to address the slow and sporadic nature of the recruitment system and the issue of job insecurity among medical officers, which in turn affects their other employment benefits, such as salary, pension, and recognition for the years of service.

Is the quality of public health facilities always worse compared to private health facilities: Association between birthplace on neonatal deaths in the Indian states

BACKGROUND

The role of place of delivery on the neonatal health outcomes are very crucial. Although the quality of care is being improved, there is no consensus about who is the better healthcare provider in low and middle-income countries (LMICs), public or private facilities. The aim of this study is to assess the differentials in neonatal mortality by the type of healthcare providers in India and its states.

METHODS

We used the data from the fourth wave of the National Family Health Survey 2015-16 (NFHS-4). Information on 259,627 live births to women within the five years preceding the survey was examined. Neonatal mortality rates for state and national levels were calculated using DHS methodology. Multi-variate logistics regression was performed to find the effect of birthplace on neonatal deaths. Propensity score matching (PSM) was used to evaluate the relationship between place of delivery and neonatal deaths to account for the bias attributable to observable covariates.

RESULTS

The rise in parity of the women and purchasing power influences the choice of healthcare providers. Increased neonatal mortality was found in private hospital delivery compared to public hospitals in Punjab, Rajasthan, Chhattisgarh, Madhya Pradesh, Bihar, Jharkhand, Odisha, Goa, Maharashtra, Andhra Pradesh and Karnataka states using propensity score matching analysis. However, analysis on the standard of pre-natal and post-natal care indicates that private hospitals generally outperformed public hospitals.

CONCLUSIONS

The study observed a significant variation in neonatal mortality among public and private health care systems in India. Findings of the study urges that more attention be paid to the improve care at the place of delivery to improve neonatal health. There is a need of strengthened national health policy and public-private partnerships in order to improve maternal and child health care in both private and public health facilities.

In search of a fix to the primary health care chasm in India: can institutionalizing a public health cadre and inducting family physicians be the answer?

India's woes with an underprioritized and hence underfunded and understaffed public health system continue to plague public healthcare delivery. Though the need for appropriately qualified public health cadre to lead public health programmes is well established, a well-meaning conducive approach to implementing this is lacking. As the COVID-19 pandemic brought back the focus on India's fragmented health system and primary healthcare deficiencies, we discuss the primary healthcare conundrum in India in search of a quintessential fix. We argue for instituting a well-thought and inclusive public health cadre to lead preventive and promotive public health programmes and manage public health delivery. With the aim being to increase community confidence in primary health care, along with the need to augment primary healthcare infrastructure, we argue for a need to augment primary healthcare with physicians trained in family medicine. Provisioning medical officers and general practitioners trained in family medicine can salvage community's confidence in primary care, increase primary healthcare utilization, stymie over-specialization of care, channelize and prioritize referrals, and guarantee competence in healthcare quality for rural communities.

Workforce problems at rural public health-centres in India: a WISN retrospective analysis and national-level modelling study

BACKGROUND

Rural India has a severe shortage of human resources for health (HRH). The National Rural Health Mission (NRHM) deploys HRH in the rural public health system to tackle shortages. Sanctioning under NRHM does not account for workload resulting in inadequate and inequitable HRH allocation. The Workforce Indicators of Staffing Needs (WISN) approach can identify shortages and inform appropriate sanctioning norms. India currently lacks nationally relevant WISN estimates. We used existing data and modelling techniques to synthesize such estimates.

METHODS

We conducted a retrospective analysis of existing survey data for 93 facilities from 5 states over 8 years to create WISN calculations for HRH cadres at primary and community health centres (PHCs and CHCs) in rural areas. We modelled nationally representative average WISN-based requirements for specialist doctors at CHCs, general doctors and nurses at PHCs and CHCs. For 2019, we calculated national and state-level overall and per-centre WISN differences and ratios to depict shortage and workload pressure. We checked correlations between WISN ratios for cadres at a given centre-type to assess joint workload pressure. We evaluated the gaps between WISN-based requirements and sanctioned posts to investigate suboptimal sanctioning through concordance analysis and difference comparisons.

RESULTS

In 2019, at the national-level, WISN differences depicted workforce shortages for all considered HRH cadres. WISN ratios showed that nurses at PHCs and CHCs, and all specialist doctors at CHCs had very high workload pressure. States with more workload on PHC-doctors also had more workload on PHC-nurses depicting an augmenting or compounding effect on workload pressure across cadres. A similar result was seen for CHC-specialist pairs-physicians and surgeons, physicians and paediatricians, and paediatricians and obstetricians-gynaecologists. We found poor concordance between current sanctioning norms and WISN-based requirements with all cadres facing under-sanctioning. We also present across-state variations in workforce problems, workload pressure and sanctioning problems.

CONCLUSION

We demonstrate the use of WISN calculations based on available data and modelling techniques for national-level estimation. Our findings suggest prioritising nurses and specialists in the rural public health system and updating the existing sanctioning norms based on workload assessments. Workload-based rural HRH deployment can ensure adequate availability and optimal distribution.

Gaps in facilities available at Community Health Centers/Rural Hospitals as per Indian public health standards - Study from Western Maharashtra

Background:

The launch of the National Rural Health Mission (NRHM) gives us the opportunity to review the functioning and bring up the Community Health Centers (CHC) services to the level of Indian Public Health Standards and thus improve the lives of citizens.

Objectives:

Assessment of the gaps in the facilities available at Community health centers/Rural hospitals as per Indian Public health standards.

Methods:

Facility based cross-sectional study was conducted in the Satara district of Maharashtra.

Results:

This study in the majority showed that the gap in the delivery of healthcare according to IPHS. It was observed that the Funded CHCs had a better quality of services than the non-funded CHCs. The non-funded CHCs lacked essential emergency services. Along with ANC care, newborn care in the first few minutes of life is very crucial, but very little priority was given to the newborn care as those services were not as per norms. Specialists as well as paramedical and other support staff are deficient in both funded and non funded CHCs/rural hospitals (RHs).

Conclusion:

Standards were greatly influenced by funds delivered by IPHS itself. A staffing pattern is one of the important pillars in delivering various health services. A better salary, working place with continuous water supply, electricity, and cleanliness will improve the staffing pattern. Therefore, competent manpower and well-built infrastructure will help in the standard delivery of healthcare at CHC/RH and will thus serve the purpose of dispensing basic health services to every individual in the remotest areas.

Frameworks for evaluation of community health centers' services and outcomes: a scoping review protocol

The objective of this scoping review is to identify and map the frameworks used to evaluate services and outcomes of community health centers within the broader context of primary health care.The primary question for this scoping review is: what are the frameworks used to evaluate services and outcomes of community health centers?Secondary questions for this review are.

Can India's primary care facilities deliver? A cross-sectional assessment of the Indian public health system's capacity for basic delivery and newborn services

OBJECTIVES

To assess input and process capacity for basic delivery and newborn (intrapartum care hereafter) care in the Indian public health system and to describe differences in facility capacity between rural and urban areas and across states.

DESIGN

Cross-sectional study.

SETTING

Data from the nationally representative 2012-2014 District Level Household and Facility Survey, which includes a census of community health centres (CHC) and sample of primary health centres (PHC) across 30 states and union territories in India.

PARTICIPANTS

8536 PHCs and 4810 CHCs.

OUTCOME MEASURES

We developed a summative index of 33 structural and process capacity items matching the Indian Public Health Standards for PHCs as a metric of minimum facility capacity for intrapartum care. We assessed differences in performance on this index across facility type and location.

RESULTS

About 30% of PHCs and 5% of CHCs reported not offering any intrapartum care. Among those offering services, volumes were low: median monthly delivery volume was 8 (IQR=13) in PHCs and 41 (IQR=73) in CHCs. Both PHCs and CHCs failed to meet the national standards for basic intrapartum care capacity. Mean facility capacity was low in PHCs in both urban (0.64) and rural (0.63) areas, while in CHCs, capacity was slightly higher in urban areas (0.77vs0.74). Gaps were most striking in availability of skilled human resources and emergency obstetric services. Poor capacity facilities were more concentrated in the more impoverished states, with 37% of districts from these states receiving scores in the lowest third of the facility capacity index (<0.70), compared with 21% of districts otherwise.

CONCLUSIONS

Basic intrapartum care capacity in Indian public primary care facilities is weak in both rural and urban areas, especially lacking in the poorest states with worst health outcomes. Improving maternal and newborn health outcomes will require focused attention to quality measurement, accountability mechanisms and quality improvement. Policies to address deficits in skilled providers and emergency service availability are urgently required.

Assessment of Newborn Care Corner in Public Health Facilities of Ludhiana, India

In this cross-sectional study of 15 public health facilities in Ludhiana, India, we evaluated 22 delivery points for equipment and trained health personal available at Newborn Care Corner (NBCC) for neonatal resuscitation. NBCCs were established at all the delivery points except one, with radiant warmers in place including non-functional warmers at four (18%) delivery points. Self-inflating resuscitation bag was available at 20 delivery points but shoulder roll and masks of both sizes were available at only 4 (18%) and 5 (27%) delivery points, respectively. Only 4 (27%) facilities had round-the-clock availability of a nurse or midwife trained in neonatal resuscitation, whereas none of the facility had round the clock availability of medical officer trained in neonatal resuscitation.

Strengthening primary level health service delivery: lessons from a state in India

The main aim of the study was to assess primary health centers (PHCs) in terms of availability of assured services, facility of primary management of selected cases, surgeries, maternal and newborn health care services, and child health care services with respect to Indian Public Health Standards (IPHS). Data were collected from service providers (medical officerin-charge) at PHCs through well-structured questionnaire developed by referring the IPHS for PHCs prescribed by the Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. The study was conducted at five districts (i.e. Bundi, SawaiMadhopur, Kota, Tonk, and Karauli) of Rajasthan state of India. All 148 PHCs of these five districts were included in the study. Findings depict that more than 90% of the study PHCs showed availability of services such as outpatient department (OPD), antenatal check up (ANC), postnatal check up (PNC), management of reproductive tract infections/sexual transmitted infection (RTI/STI), immunization, and treatment of diarrhea. However, services such as emergency services (24 h), primary management of fractures, surgery of cataract, medical termination of pregnancy (MTP) services, management of low-birth-weight babies, facility for tubectomy and vasectomy, and facility for internal examination for gynecological conditions were poor at PHCs of the study districts, which need to be addressed for further strengthening of primary health centers.